Atlas Phẫu Thuật Mí Mắt Và Hốc Mắt – Jonathan Dutton (2012)

94
SEC ION G ▲ Blepharoptosis
FIG. 24.9. Slide one jaw of a Berke ptosis clamp beneath the levator muscle just
above the level of Whitnall’s ligament. ighten the clamp.
FIG. 24.10. With scissors, cut the levator muscle between the clamp and
Whitnall’s ligament.
FIG. 24.11. Evert the levator muscle by pulling the clamp upward. Divide the
fascial connections between the levator and the underlying superior rectus muscle
and conjunctiva superiorly for 10 to 15 mm, depending upon the amount of planned
resection.
FIG. 24.12. Pass three double-armed 6-0 prolene sutures through partial thick-
ness of the tarsus, near its superior border.
FIG. 24.13. Advance the levator muscle over Whitnall’s ligament and over the
intact aponeurosis and Müller’s muscle to the tarsus. Pass the central prolene
suture through the levator muscle Z mm above the cut edge as determined in
Fig. 24.7.
FIG. 24.14. Remove the Berke ptosis clamp. Note the position of the upper eyelid.
T e lid margin should rest at or within 1 mm of the superior corneal limbus. If it does
not, reposition the prolene suture.
FIG. 24.15. Pass the nasal and temporal prolene sutures through the levator
muscle and adjust their positions to achieve an adequate eyelid contour. Excise
any excess levator muscle distal to the sutures with Westcott scissors.
FIG. 24.16. Use scissors to remove a strip of skin and orbicularis muscle from
along the upper edge of the wound if necessary to prevent overhang. T is is
frequently needed with larger resections for congenital ptosis. Close the skin with a
running suture of 6-0 fast-absorbing plain gut. Reform the eyelid crease if necessary by
incorporating the bite through the levator muscle on every second or third loop.
POSTOPERATIVE CARE: Apply iced compresses inter-
mittently or 24 hours. Place ophthalmic ointment on the
globe at the end o the operation and every 2 hours or 24
hours. T erea ter, apply ointment our times daily and at
bedtime or 1 week. Substitute artif cial tears during the
day, but continue applying ointment at bedtime or at least
4 weeks. Adults may have to continue bedtime application
indef nitely.
POTENTIAL COMPLICATIONS:
Undercorrection—T is is a common occurrence, espe-
cially in poor unction cases. A ter several months,
additional resection can be per ormed, using the
same criteria as used initially. A tarsectomy procedure
per ormed transcutaneously works well or smaller
amounts o undercorrection.
Overcorrection—T is is seen rarely in primary repair o
congenital ptosis but is more commonly seen in repeat
operations and adults. Massage and time may resolve
small overcorrections o 1 to 2 mm. For larger or persis-
tent overcorrections, levator muscle recession or a hori-
zontal tarsotomy with gaping o the wound may be use ul.
Prolapse of conjunctiva—T is results rom loss o or-
niceal ascial suspension during dissection. I it is rec-
ognized intraoperatively, ref x the ornix with several
double-armed 4-0 chromic sutures passed rom the
conjunctiva through the levator muscle. Postoperatively,
prolapse is corrected with ull-thickness eyelid sutures
passed rom conjunctiva to skin. With chronic edema
and hypertrophy, a portion o the thickened conjunctiva
may have to be excised.
Poor eyelid crease—T is is caused by ailure to re orm
the crease during closure or rom an overhang o excess
skin. It is repaired with a secondary crease re ormation
procedure, or blepharoplasty.
Poor eyelid contour—T is ollows inadequate adjustment
o sutures intraoperatively. T is is best repaired within 1
week a ter surgery with urther advancement or reces-
sion o the levator muscle. Later, segmental tarsotomy
or tarsectomy will correct small de ects.

95
CHAP ER 24 ▼ Supra-Whitnall’s Ligament Levator Muscle Resection
FIG. 24.9
FIG. 24.13
FIG. 24.10
FIG. 24.14
FIG. 24.11
FIG. 24.15
FIG. 24.12
FIG. 24.16

96
collagen bundles in the fascia. T ese will usually approximate
the direction of the external leg line.
FIG. 25.5. Using blunt dissection with long-handled
Metzenbaum scissors, separate the fascia from the
underlying vastus lateralis muscle for a distance of 15 cm
along the marked leg line.
FIG. 25.6. Pass the fascial tongue into the cutting port of
a Crawford or other fascial stripper and secure it with a
straight hemostat. Advance the fascial stripper 15 cm into
the wound, parallel to the collagen bundles, while holding the
fascia taut with the hemostat. Release the cutting blade lock,
cut the strip, and withdraw it from the wound. If there is a
small amount of bleeding, apply pressure for 5 minutes.
FIG. 25.7. Trim away any adherent fat or areolar tissue and
carefully cut the fascia into 2-mm wide strips. ake care to
make these cuts parallel to the collagen bundles. Wrap the
strips in a saline-moistened sponge and set them aside.
FIG. 25.8. Close the leg wound with deep, interrupted
4-0 chromic sutures and vertical mattress sutures of 5-0 silk
or Vicryl. Do not close the defect in the fascia.
FIG. 25.1. Straighten the leg with the toes turned medially.
Mark the approximate direction of bers in the iliotibial tract
with a line sited between the lateral femoral condyle and a
point 1 to 2 cm behind the anterior superior iliac crest. With
two short cross-marks, de ne a 2-cm segment of this line 6 cm
above the lateral condyle of the femur. Inject 0.5 mL of local
anesthetic with 1:100,000 epinephrine subcutaneously beneath
this short segment.
FIG. 25.2. Cut through the skin with a scalpel blade along
the 2-cm segment previously marked and dissect through
subcutaneous fat to the level of the fascia lata. T ere may be
a thin membrane beneath the fat, which obscures the fascia.
FIG. 25.3. Bluntly dissect upward between the fascia lata
and the overlying fat with a long-handled Metzenbaum
scissors. Extend the dissection for a distance of 15 cm along the
externally marked leg line by pushing the closed scissors into the
wound, opening the scissors, and withdrawing it without closing
again. T is separates the fascia and prevents later bleeding.
FIG. 25.4. Cut a tongue in the fascia 1 cm wide and 2 cm
long, with its attached base toward the patient's head.
Carefully align the longitudinal cuts with the direction of
INDICATIONS: For use in rontalis f xation procedures and eyelid reconstructions.
CONTRAINDICATIONS: T e ascia lata is thin and poorly developed in children under 3 years old.
25
Harvesting Autogenous Fascia Lata
POSTOPERATIVE CARE: Apply a f rm, nonencircling
pressure dressing or 48 hours. T erea ter, place a light
dressing daily until the sutures are removed. Place antibi-
otic ointment on the suture line our times daily or 7 days.
Remove the skin sutures a ter 7 days.
POTENTIAL COMPLICATIONS:
Infection—T is is uncommon; however, because o its
location, the wound is more di cult to keep clean. Sys-
temic antibiotics may be used postoperatively, although
they are not routinely necessary.
Leg pain—Discom ort along the site o ascia removal is
requent with ambulation. his typically resolves within
1 to 2 weeks.
Poor scar formation—T e skin over the lateral thigh is
thick, and especially in children, scar ormation may on
rare occasions be exuberant. Care ully close the under-
lying at and dermal layers separately, and use vertical
mattress sutures on the skin to evert and slightly pucker
the wound to avoid later depression.

97
CHAP ER 25 ▼ Harvesting Autogenous Fascia Lata
FIG. 25.1
FIG. 25.5
FIG. 25.2
FIG. 25.6
FIG. 25.3
FIG. 25.7
FIG. 25.4
FIG. 25.8

98
26
FIG. 26.4. T read a strip of prepared autogenous or
preserved fascia into the eyelet of the Wright needle, and
pull it through to the brow incision.
FIG. 26.5. Pass the Wright needle from the central to the
lateral eyelid incision. T read the free end of the fascia
into the needle eyelet, and pull the strip into the central lid
incision.
FIG. 26.6. Reinsert the Wright needle into the lateral brow
incision and pass it toward the central eyelid incision.
T read the fascia into the eyelet.
FIG. 26.7. Pull the fascia to the lateral brow incision to
complete a triangle, with its short arm along the lateral
eyelid margin and its apex at the lateral brow.
FIG. 26.8. T read a second strip of fascia between the
medial brow and eyelid incisions in similar fashion to form
a second triangle, with its short arm along the medial eyelid
margin and its apex at the medial brow. T e two triangles
meet at the central lid incision.
FIG. 26.1. Place three short guide marks 2 mm above the
lash line, one above the pupil and one each above the
junctional thirds of the lid margin. Elevate the lid to the
desired height and site lines perpendicular to the lid margin
above the lateral and medial guide marks. Mark a line 3 mm
in length at the points where the perpendicular line intersects
the upper border of the brow. Place another 3 mm line midway
between these two brow marks and 1 cm above them.
FIG. 26.2. Make stab incisions at the three brow marks
through the skin and frontalis muscle. Place a lid plate
beneath the upper eyelid, and make stab incisions to the
level of the tarsus at the three previously placed marginal
guide marks. Bleeding is controlled with pressure for several
minutes.
FIG. 26.3. Place a lid plate beneath the eyelid to the orbital
rim, and pass a Wright fascia needle from the lateral brow
stab incision toward the lateral lid incision. As the needle
passes over the brow ridge, direct it slightly backward to
remain deep to the orbicularis muscle. Continue advancing the
needle at a level just anterior to the levator aponeurosis and
the tarsus.
INDICA IONS: Severe ptosis with very poor to absent levator muscle unction o 3 mm or less.
CON RAINDICA IONS: Ptosis with ≥6 mm o unction. Caution is required in patients with impaired Bell’s phenomenon.
Frontalis Muscle Suspension with
Autogenous Fascia Lata

99
CHAP ER 26 ▼ Frontalis Muscle Suspension with Autogenous Fascia Lata
FIG. 26.3
FIG. 26.2
FIG. 26.1
FIG. 26.4
FIG. 26.5
FIG. 26.7
FIG. 26.6
FIG. 26.8

100 SEC ION G ▲ Blepharoptosis
FIG. 26.9. ie the ends of the fascial strips with a square knot and adjust the
tension to produce a normal eyelid contour. Place the height about 1 to 2 mm
higher than the nal desired level or at the superior corneal limbus. Secure the knot at
each brow incision with a 6-0 prolene suture to prevent slippage.
FIG. 26.10. Pass the Wright needle from the central brow incision to the lateral
brow incision and pull through one end of the fascial strip. Repeat this procedure
to pull one end of the medial strip to the central brow.
FIG. 26.11. ie the strips together at the central brow incision with a square
knot. Adjust the tension on each strip to maintain the eyelid margin contour.
FIG. 26.12. Secure the knot with a 6-0 prolene suture to prevent slippage.
FIG. 26.13. Push the fascial knots to the base of the wounds. rim all the fascia
ends to 1 cm in length and push these ends into pockets beneath the frontalis muscle
with smooth dressing forceps.
FIG. 26.14. Close all three brow incisions with a 6-0 fast-absorbing plain gut. T e
eyelid incisions need not be closed.
POS OPERA IVE CARE: Apply iced compresses inter-
mittently or 24 hours. Place ophthalmic ointment on the
globe immediately, our times daily, and at bedtime or 7
days. Continue the bedtime ointment application or sev-
eral weeks with children and several months with adults.
PO EN IAL COMPLICA IONS:
Undercorrection—T is is caused by ailure to position the
lid at the superior limbus when the knot is tied. Pushing
the knot into the wound results in lowering o the lid
by 1 to 1.5 mm. I recognized within the f rst week, the
ascia can be retrieved at the brow wounds and relied.
A ter f brosis, a new sling will be needed.
Overcorrection—T is is exceptionally rare in children but
is more common in adults. T e sling may loosen with
vigorous massage. A ter f brosis has developed along
the sling, cutting the ascial strip will allow some reces-
sion o the lid. Fibrosis along the strip prevents complete
return o ptosis.
Lagophthalmos—T is is a very common sequel to ron-
talis suspension. T e condition is temporized with
artif cial tears and ophthalmic ointments until the cor-
nea adapts to chronic exposure. I keratitis is severe
and persistent, especially in adults, the sling may have
to be lowered.
Ectropion—T is results rom placing the sling too close to
the lid margin, especially when the eyes are deep set or
the brow ridges are prominent. I mild, it may resolve
with time. Small amounts o ectropion can be corrected
with minimal lid shortening at the lateral canthus. I
ectropion is more severe, the sling must be reversed.
Entropion—T is is caused by ailure to excise overhang
o excess skin or rom placing the sling too close to the
upper tarsal border. I necessary, an eyelid crease orma-
tion procedure can be per ormed with excision o a strip
o skin and orbicularis muscle rom the upper skin edge
prior to closure. Occasionally, the sling may have to be
replaced.
Poor lift contour—T is results rom inadequate adjust-
ment at the time o surgery. I noted intraoperatively,
slide the lid margin over the sling, using orceps to
adjust the contour.

101
CHAP ER 26 ▼ Frontalis Muscle Suspension with Autogenous Fascia Lata
FIG. 26.10
FIG. 26.11
FIG. 26.12
FIG. 26.13
FIG. 26.14
FIG. 26.9

102
27
the needle eyelet and pull them through to the brow incisions.
T en pass the Wright needle from the central brow incision
to each of the medial and lateral incisions and pull the rod
through so that both emerge from the central incision.
FIG. 27.5. Pass the silicone rod ends through a silicone band
in opposite directions. A Watsky sleeve spreader will facilitate
this operation.
FIG. 27.6. Before tightening the rod, close the upper eyelid inci-
sion with a running suture of 6-0 fast-absorbing gut. ighten
the silicone sling by pulling the ends through the sleeve until the
eyelid margin is at or just below the superior corneal limbus. Synch
the band with an interrupted suture of 6-0 prolene.
FIG. 27.7. Close the medial and lateral brow incisions with
one or two interrupted sutures. Cut the free ends of the
silicone rod to a length of about 1 cm. With a narrow smooth
dressing forceps, grasp each end of the rod and push it into the
wound beneath the frontalis muscle. Make sure it lies at and
is not bucked to prevent extrusion.
FIG. 27.8. Close the central brow incision with one or two
interrupted sutures of 6-0 fast-absorbing plain gut.
FIG. 27.1. Mark an incision line at the upper eyelid crease.
Mark two small 5-mm lines at the upper medial and lateral
brow and one centrally about 5 to 8 mm above these. In ltrate
the eyelid with 0.5 to 1.0 mL local anesthetic. Also, in ltrate
along the superior orbital rim and beneath the eyebrow. Hold
the lid taut to prevent buckling and incise the skin with a scal-
pel blade. Make stab incisions at the brow marks.
FIG. 27.2. Cut through the orbicularis muscle with a scissors
and open it to the full extent of the wound. Continue the dissec-
tion inferiorly to expose the anterior surface of the tarsus. Separate
the orbicularis from the tarsus for a distance of about 6 to 8 mm.
FIG. 27.3. Place a 1-mm-diameter silicone rod with the
wire introducers removed horizontally across the tarsus.
Suture the rod to the tarsus with three interrupted sutures
of 6-0 prolene. T e medial and lateral sutures should be
approximately over the medial and lateral corneal limbus. Be
careful not to penetrate to the conjunctival surface.
FIG. 27.4. Place a lid plate beneath the lid and pass a Wright
fascia needle from the medial and lateral brow incisions,
over the orbital rim, and then behind the orbital septum
toward the tarsus. T read the ends of the silicone rod through
INDICATIONS: Severe ptosis with very poor to absent levator muscle unction o 3 mm or less.
CONTRAINDICATIONS: Ptosis with ≥6 mm o unction. Caution is required in patients with impaired Bell’s phenomenon
or those at risk or corneal exposure.
Frontalis Muscle Suspension
with Silicone Rod
POSTOPERATIVE CARE: Apply iced compresses contin-
uously or 2 hours and intermittently or 24 hours. Place
ophthalmic ointment on the globe immediately, our times
daily, and at bedtime or 7 days. Continue the bedtime
ointment application or several weeks with children and
several months with adults. For young children, the bed-
time application should be continued indef nitely.
POTENTIAL COMPLICATIONS:
Undercorrection—T is is caused by ailure to position the lid
at the superior limbus when the silicone band is synched.
Pushing the knot into the wound results in lowering o the
lid by 1 to 1.5 mm. With silicone, the sling can be adjusted
at any time postoperatively, even many years later.
Overcorrection—T is is rare in children but is more com-
mon in adults. I there is corneal compromise, the cen-
tral brow incision can be opened and the sling loosened.
Lagophthalmos—T is is a very common sequel to rontalis
suspension. T e condition is temporized with artif cial
tears and ophthalmic ointments until the cornea adapts
to chronic exposure. I keratitis is signif cant and persis-
tent, especially in adults, the sling may have to be lowered.
Ectropion—T is results rom suturing the sling too close
to the lid margin, especially when the eyes are deep set
or the brow ridges are prominent. I mild, it may resolve
with time. I ectropion is more severe, the sling must be
revised.
Entropion—T is is caused by ailure to excise overhang
o excess skin or rom placing the sling too close to the
upper tarsal border. I necessary, an eyelid crease orma-
tion procedure can be per ormed with excision o a strip
o skin and orbicularis muscle rom the upper skin edge
prior to closure. Occasionally, the sling may have to be
repositioned on the tarsus.

103
CHAP ER 27 ▼ Frontalis Muscle Suspension with Silicone Rod
FIG. 27.6
FIG. 27.5
FIG. 27.8
FIG. 27.4
FIG. 27.2
FIG. 27.1
FIG. 27.7
FIG. 27.3

104
H
SECTION
Ectropion
I
n ectropion, the eyelid margin is turned outward, away
rom the globe. T is leads to inadequate corneal protec-
tion, discom ort, and ultimately epithelial and stromal injury.
ear drainage dys unction results rom poor apposition o
the puncta to the globe. T e causes are varied, and correction
must be directed at the source o the pathologic process.
T e most common etiology is involutional eyelid redun-
dancy. T e laxity may be dif use, involving the entire lid
margin. More commonly, however, laxity is con ned to
the lateral one-hal o the lid, where it results rom stretch-
ing o the lateral canthal ligament and loss o horizontal
eyelid support. Less requently, the thicker medial canthal
ligament may be redundant, resulting in punctal eversion.
Laxity o the orbicularis muscle and overlying skin urther
contribute to loss o eyelid tone, thus exacerbating the
ectropion. Involutional ectropion is con ned to the lower
eyelid. Because gravity tends to hold the upper lid in posi-
tion against the globe, ectropion resulting rom laxity is not
seen here. A variant o laxity-induced ectropion that does
af ect the upper eyelid is the oppy eyelid syndrome, which
is seen occasionally in obese males and less commonly in
emales. With this orm o ectropion, the tarsus is redun-
dant, causing eversion during sleep.
During examination, patients with involutional ectropion
show some degree o eyelid redundancy on the pinch test.
T e latter is per ormed by pulling the lower lid away rom
the globe. A orward displacement o more than 8 mm is
abnormal. Upon release, the lid does not snap back to its or-
mer position but dri ts slowly, sometimes requiring a blink
be ore complete return to apposition with the globe. T ese
signs con rm abnormal laxity. In the presence o medial
canthal ligament redundancy, pulling the eyelid margin lat-
erally causes displacement o the in erior punctum toward
the nasal corneal limbus. Similarly, when lateral canthal
ligament laxity is prominent, pulling the lid medially causes
movement o the lateral canthal angle toward the temporal
limbus. With signi cant medial lid eversion, stenosis and
occlusion o the in erior punctum is requently seen, with
tear pooling and over ow. Corneal exposure is common and
may be associated with super cial punctate keratopathy.
Keratinization o the conjunctiva and in ammatory in ltra-
tion result in lid thickening and urther ectropion.
Repair o involutional ectropion is directed at tightening
o the lax components o eyelid structure. Frequently, this
requires the simultaneous correction o several abnormal ele-
ments such as the lateral canthal ligament and the orbicularis
muscle. T e most use ul lid shortening procedures include
the lateral tarsal strip xation or canthal ligament recon-
struction and the simple wedge resection with or without
orbicularis tightening. T ese may be used on the upper as
well as the lower eyelid. Lid shortening alone may not always
correct punctal eversion, in which case, it can be combined
with a medial spindle tarsoconjunctival resection. When
long-standing ectropion has resulted in secondary de ormi-
ties, such as punctal occlusion or cicatricial eyelid retraction,
other procedures may have to be added. T ese include punc-
toplasty or canaliculoplasty, recession o the eyelid retrac-
tors, or release o the cicatrized subcutaneous tissues.
In paralytic ectropion resulting rom seventh nerve
dys unction, the canthal ligaments are requently normal.
However, loss o orbicularis muscle tone results in outward
displacement o the lower lid under the in uence o grav-
ity and the downward traction o a droopy cheek. Paralytic
ectropion is o ten associated with brow ptosis and second-
ary dermatochalasis, pseudoptosis o the upper eyelid, and
drooping o the lateral canthal angle. With long-standing
downward tension on the atonic eyelid, progressive stretch-
ing occurs so that laxity becomes an additional component.
T e goals in the management o paralytic ectropion are
protection o the cornea, ocular com ort, and improved
cosmesis. When ectropion is mild, a simple tarsorrhaphy
shortens the horizontal interpalpebral ssure, provides
minimal vertical support or the lateral lower lid, and reap-
poses the lid margins to the globe. With greater degrees o
ectropion, especially when signi cant acial droop is also
present, a tarsorrhaphy alone does not usually withstand
the continued downward tension, and results are tempo-
rary at best. Lid shortening achieves good unctional and
cosmetic results but must be combined with subcutaneous
cheek suspension to relieve downward traction. When ten-
sional orces are marked, more substantial lid support is
required. T is is achieved with a ascial sling or temporalis
muscle trans er procedure.
In cicatricial ectropion, the anterior skin or skin–mus-
cle lamella is shortened, resulting in outward orces on the
lid margin. It is seen in both the upper and lower eyelid
and may be associated with dermatologic disorders, such
as rosacea and ichthyosis, traumatic scarring, burns, in ec-
tion, radiation, or sequelae to eyelid surgery. Secondary
complications that involve the puncta, conjunctiva, and
cornea may be seen as with other orms o ectropion.
Correction is directed at replacing the de cient tissue with
local aps or ree skin gra ts.
Mechanical ectropion results rom mass lesions that
interpose between the eyelid and the globe. T e lesions
may be conjunctival or subconjunctival in ltrates, lid or
epibulbar tumors, or abscesses. reatment involves medi-
cal or surgical elimination o the causative lesion.

Medial Spindle arsoconjunctival Resection
Mulhern MG, Sheikh I, Subrayan V, et al. T e E-Z(easy) clamp—a new
instrument to acilitate medial ectropion repair. Orbit. 2005;24:109–111.
Nowinski S, Anderson RL. T e medial spindle procedure or involu-
tional medial ectropion. Arch Ophthalmol. 1985;103:1750–1753.
O’Donnell FEJ. Medial ectropion associated with lower lacrimal obstruc-
tion and combined management. Ophthal Surg. 1986;17:573–576.
Full-T ickness Marginal Wedge Resection
Fox SA. A modi ed Kuhnt-Szymanowski procedure. Am J Ophthalmol.
1966;62:533–536.
Leone Jr CR.. Repair o senile ectropion. In: Ashton SJ, ed. T ird Interna-
tional Symposium of Plastic Surgery of the Eye and Adnexa. Baltimore,
MD: Williams & Wilkins; 1982.
T e Modi ed Lazy Procedure
Bosniak SL. Ectropion. In: Smith BC, Delia Rocca RC, Nesi FA, Lis-
man RD, eds. Ophthalmic Plastic and Reconstructive Surgery. Vol 1.
St. Louis: Mosby-Year Book; 1987.
Ferguson AW, Chadha V, Kearns PP. T e not-so-lazy- : a modi cation o
medial ectropion repair. Surgeon. 2006;4:87–89.
Smith B. T e “lazy- ” correction o ectropion o the lower punctum. Arch
Ophthalmol. 1976;94:1149–1150.
Medial Canthal Ligament Plication
Fante RG, Elner VM. ranscaruncular approach to medial canthal tendon pli-
cation or lower eyelid laxity. Ophthal Plast Reconstr Surg. 2001;17:16–27.
Fong KC, Mavrikakis I, Sagili S, Malhotra R. Correction o involutional
lower eyelid medial ectropion with transconjunctival approach
retractor plication and lateral tarsal strip. Acta Ophthalmol Scand.
2006;84:246–249.
Jelks GW, Smith B, Bosniak S. T e evaluation and management o the eye
in acial palsy. Clin Plast Surg. 1979;6:397–419.
Olver JM, Sathia PJ, Wright M. Lower eyelid medial canthal tendon laxity
grading: an interobserver study o normal subjects. Ophthalmology.
2001;108:2321–2325.
Sodhi PK, Verma L, Pandey RM, Ratan SK. Appraisal o a modi ed medial
canthal plication or treating laxity o the medial lower eyelid. J Cra-
niomaxillofac Surg. 2005;33:205–209.
Fascial Suspension Procedure
de la orre J, Simpson RL, enenhaus M, Bourhill I. Using lower eye-
lid ascial slings or recalcitrant burn ectropion. Ann Plast Surg.
2001;46:621–624.
Vistnes LM, Iverson RE, Laub DR. T e anophthalmic orbit, surgical cor-
rection o lower eyelid ptosis. Plast Reconstr Surg. 1973;52:346.
Weinstein GS, Anderson RL, se D , et al. T e use o a periosteal strip or
eyelid reconstruction. Arch Ophthalmol. 1985;103:357–359.
Wiggs EO, Guibor P, Hecht SD, et al. Surgical treatment o the denervated
or sagging lower lid. Ophthalmology. 1982;89:428–432.
Anterior Lamellar Lengthening with Skin Graft
Bosniak S. Ectropion. In: Smith B, Delia Rocca RC, Nesi F, Lisman RD,
eds. Ophthalmic Plastic and Reconstructive Surgery. Vol 1. St. Louis,
MO: Mosby-Year Book; 1987.
Osborne SF, Eidsness RB, Carroll SC, Rosser PM. T e use o brin tissue
glue in the repair o cicatricial ectropion o the lower eyelid. Ophthal
Plast Reconstr Surg. 2010;26:409–412.
Stasior OG. Cicatricial ectropion. In: Ashton SJ, ed. T ird Intl Symposium
of Plastic and Reconstructive Surgery of the Eye and Adnexa. Balti-
more, MD: Williams & Williams; 1982.
SUGGESTED FURTHER READING
Ectropion
Bedran EG, Pereira MV, Bernardes F. Ectropion. Semin Ophthalmol.
2010;25:59–65.
Chung JE, Yen M . Mid ace li ting as an adjunct procedure in ectropion
repair. Ann Plast Surg. 2007;59:635–640.
Damasceno RW, Heindl LM, Ho mann-Rummelt C, et al. Pathogenesis
o involutional ectropion and entropion: the involvement o matrix
metalloproteinases in elastic ber degradation. Orbit. 2011;30:
132–139.
Damasceno RW, Osaki MH, Dantas PE, Bel ort R Jr. Involutional entro-
pion and ectropion o the lower eyelid: prevalence and associated
risk actors in the elderly population. Ophthal Plast Reconstr Surg.
2011;27:317–320.
Fezza JP. Nonsurgical treatment o cicatricial ectropion with hyaluronic
acid ller. Plast Reconstr Surg. 2008;121:1009–1014.
Goldberg RA. Use o a suture anchor or correction o ectropion in acial
paralysis. Plast Reconstr Surg. 2006;117:675–676.
Heimmel MR, Enzer YR, Ho mann RJ. Entropion-ectropion: the in uence
o axial globe projection on lower eyelid malposition. Ophthal Plast
Reconstr Surg. 2009;25:7–9.
Kahana A, Lucarelli MJ. Adjunctive transcanthotomy lateral suborbicu-
laris at li t and orbitomalar ligament resuspension in lower eyelid
ectropion repair. Ophthal Plast Reconstr Surg. 2009;25:1–6.
Nainiwal S, Kumar H, Kumar A. Laser conjunctivoplasty: a new technique
or correction o mild medial ectropion. Orbit. 2003;22:199–201.
Osborne SF, Eidsness RB, Carroll SC, Rosser PM. T e use o brin tissue
glue in the repair o cicatricial ectropion o the lower eyelid. Ophthal
Plast Reconstr Surg. 2010;26:409–412.
Papalkar D, Francis IC, Wilcsek G. Correction o ectropion in acial paral-
ysis. Plast Reconstr Surg. 2006;117:677.
Lateral arsorrhaphy
Cole G. Lateral canthoplasty in ophthalmic plastic surgery. In: Hughes
WL, ed. Manual on Oculoplastic Surgery. San Francisco, CA: T e
American Academy o Ophthalmology; 1961.
de Silva DJ, Ramkissoon YD, Ismail AR, Beacons eld M. Surgical tech-
nique: modi ed lateral tarsorrhaphy. Ophthal Plast Reconstr Surg.
2011;27:216–218.
Garber PF. Lateral canthoplasty. In: Smith B, Bosniak S, eds. Advances in
Ophthalmic Plastic and Reconstructive Surgery. Vol 2. Elms ord, NY:
Pergamon Press; 1983.
Soll DB. Entropion and ectropion. In: Soll DB, ed. Management of Com-
plications in Ophthalmic Plastic Surgery. Birmingham, UK: Aescula-
pius; 1976.
Eyelid Shortening by Lateral arsal Strip Fixation
Anderson RL, Gordy DD. T e tarsal strip procedure. Arch Ophthalmol.
1979;97:2192–2196.
Becker FF. Lateral tarsal strip procedure or the correction o paralytic
ectropion. Laryngoscope. 1982;92:382–384.
Georgescu D, Anderson RL, McCann JD. Lateral canthal resuspension
sine canthotomy. Ophthal Plast Reconstr Surg. 2011;27:371–375.
Jordan DR, Anderson RL. T e lateral tarsal strip revisited. T e enhanced
tarsal strip. Arch Ophthalmol. 1989;107:604–606.
Vage MR, Anderson RL. T e lateral tarsal strip mini-tarsorrhaphy pro-
cedure. Arch Facial Plast Surg. 2009;11:136–139.
Wesley RE, Collins JW. McCord procedure or ectropion repair. Arch
Ophthalmol. 1983;109:319–322.
105
SEC ION H ▼ Ectropion

106
28
opposing lower lid. Sharply dissect in the postorbicular fascial
plane to a depth of 3 to 4 mm.
FIG. 28.5. Cut a strip of marginal epithelium from the
separated upper tarsus to form a free edge opposite that in
the lower eyelid.
FIG. 28.6. Pass a 6-0 Vicryl suture into the exposed anterior
surface of the lower eyelid tarsus to emerge through the free
margin at the medial extent of the split lid. Place the suture
into the free margin of the opposing upper lid tarsus and out
through its anterior surface. Add two or three additional sutures.
FIG. 28.7. Tie the sutures to oppose the tarsal surfaces.
FIG. 28.8. Allow the lash-bearing skin margins to close over
the approximated tarsal plates. It is not necessary to place
sutures across them.
FIG. 28.1. Grasp the lower eyelid margin with forceps and
cut along the gray line with a scalpel blade from the lateral
canthal angle medially for a distance of about 10 mm. T e
exact distance depends on the amount of intermarginal adhe-
sion needed.
FIG. 28.2. With micro-Westcott scissors, sharply dissect in
the postorbicular fascial plane to a depth of 3 to 4 mm to
separate the anterior skin–muscle lamella from the ante-
rior tarsus.
FIG. 28.3. Cut a strip of epithelium from the marginal bor-
der of the tarsus along the area of the split eyelid. Leave the
lashes along the skin–muscle ap intact so the tarsorrhaphy
can be taken down later without distortion of the lid margin.
FIG. 28.4. Grasp the upper eyelid margin and split the
lid along the gray line for a distance equal to that in the
INDICATIONS: Mild to moderate ectropion; mild congenital or acquired eyelid retraction.
Lateral Tarsorrhaphy
POSTOPERATIVE CARE: Place antibiotic ointment in
the lateral canthal angle and on the lid margins our times
daily or 7 days.

107
CHAP ER 28 ▼ Lateral arsorrhaphy
FIG. 28.1
FIG. 28.5
FIG. 28.2
FIG. 28.6
FIG. 28.3
FIG. 28.7
FIG. 28.4
FIG. 28.8

108
29
FIG. 29.1. Pull the eyelid medially to prevent buckling, and
with scissors, cut a lateral canthotomy to the orbital rim.
Transect the in erior crus o the lateral canthal ligament. Grasp
the lateral lid with orceps and pull it medially to con rm
interruption o all attachments.
FIG. 29.2. Split the eyelid with ne, pointed scissors along
the gray line for a distance of 5 to 10 mm, depending on the
amount of lid shortening required. Continue the dissection
to separate the anterior skin–muscle lamella rom the posterior
tarsoconjunctival lamella.
FIG. 29.3. Cut the retractors and conjunctiva from along
the inferior border of the tarsus beneath the split section.
Cauterize the palpebral vessels, which are usually injured at this
stage.
FIG. 29.4. With ne scissors, remove a strip of marginal
epithelium from the free portion of the tarsus.
FIG. 29.5. Lay the anterior surface of the ap over the
at face of a forceps handle and scrape the conjunctival
epithelium from the posterior surface of the tarsus with
a scalpel blade. Cut of the remnant o the lateral canthal
ligament rom the bare tarsus to orm a strip 3 to 4 mm wide
and 4 mm long.
FIG. 29.6. Pass a 4-0 Mersilene or Vicryl suture on a small,
half-circle needle through the tarsal strip from outside
to inside and then through the periosteum just inside the
lateral orbital rim. Tie the sutures rmly.
FIG. 29.7. With forceps, pull the skin–muscle ap laterally
and excise the excess triangle with its marginal cilia.
FIG. 29.8. Reform the canthal angle with an interrupted
suture of 6-0 fast-absorbing gut. Close the orbicularis
muscle and skin with interrupted stitches o 6-0 ast-absorbing
plain gut.
INDICATIONS: Mild to moderate horizontal laxity o the lower or upper eyelid, especially when resulting rom stretch-
ing o the lateral canthal ligament.
CONTRAINDICATIONS: Eyelid laxity resulting rom medial canthal ligament redundancy; all but the mildest orms o
cicatricial ectropion.
Eyelid Shortening by Lateral
Tarsal Strip Fixation
POSTOPERATIVE CARE: Apply antibiotic ointment to
the sutures three to our times daily or 7 days.
POTENTIAL COMPLICATIONS:
Persistent laxity—Undercorrection o laxity occurs with
ailure to adequately shorten the lid. With the patient in
the supine position, the laxity is less obvious. It is best
to slightly overtighten the lid intraoperatively because
some stretching occurs within the f rst 1 to 2 weeks.
Overcorrection—Results rom cutting the tarsal strip too
short be ore placing the f xation sutures. Mild overcor-
rection is o no consequence since the lid will stretch over
several weeks. I the strip is too short to be sutured to the
orbital rim, a small periosteal ap is elevated rom the
rim, and its ree end is sutured to the strip or f xation.
Lateral canthal angle dystopia—Elevation o the canthal
angle occurs when the suture is placed too high onto
the lateral orbital rim. T is may not be noticed until the
patient sits upright postoperatively. A slight elevation is
tolerable, but excessive elevation does not resolve spon-
taneously and should be repositioned.
Trichiasis at the lateral canthus—T is results rom ail-
ure to remove the excess lash-bearing marginal skin at
the newly re ormed canthal angle. T e o ending lashes
are removed later by excision or hy recation in a sepa-
rate procedure.
Redundancy of lateral eyelid skin— his is seen with
signi icant shortening o the lid in the presence o
dermatochalasis. I noted intraoperatively, a sub-
ciliary incision is continued rom the lateral anterior
lamellar lap and i necessary, the lateral skin incision
is continued slightly downward. A blepharoplasty
type o lap is completed with excision o excess skin
temporally.

109
CHAPTER 29 ▼ Eyelid Shortening by Lateral Tarsal Strip Fixation
FIG. 29.1
FIG. 29.5
FIG. 29.2
FIG. 29.6
FIG. 29.3
FIG. 29.7
FIG. 29.4
FIG. 29.8

110
30
FIG. 30.1. Place a no. 00 or 0 Bowman probe in the inferior
canaliculus to mark its position, and evert the lower eyelid
with forceps.
FIG. 30.2. With a scalpel blade cut a spindle-shaped
segment 8 to 10 mm long and 4 to 6 mm high from the
conjunctiva and tarsus. Locate the excision 4 mm below the
inferior punctum, positioned so two-thirds of the spindle lie
lateral to the papilla.
FIG. 30.3. Remove the Bowman probe. Pass a double-armed
4-0 chromic suture through the inferior wound edge from
inside the wound to the conjunctival surface.
FIG. 30.4. Continue passing the same sutures through
the superior wound edge from the conjunctival surface
to the subtarsal space to form a double vertical mattress
stitch.
FIG. 30.5. Pass both needles anteriorly through the
center of the spindle-shaped defect to emerge on the skin
surface.
FIG. 30.6. Tie the suture on the skin surface with enough
tension to pull the wound edges together and to invert the
lid margin and punctum.
INDICATIONS: Ectropion of the medial one-third to one-half of the eyelid with punctal eversion.
Medial Spindle Tarsoconjunctival
Resection
POSTOPERATIVE CARE: Apply antibiotic ointment to
the conjunctival fornix and skin suture twice daily until
the suture dissolves.
POTENTIAL COMPLICATIONS:
Canalicular injury—This results from placement of the
spindle excision too high on the lid or passing the
sutures too close to the canaliculus and is avoided
by careful attention to the position of the Bowman
probe.

111
CHAPTER 30 ▼ Medial Spindle Tarsoconjunctival Resection
FIG. 30.1
FIG. 30.2
FIG. 30.3
FIG. 30.4
FIG. 30.5
FIG. 30.6

112
31
FIG. 31.6. Excise the outlined triangular area with scissors.
Place two or three 6-0 Vicryl sutures across the tarsus, keeping
them beneath the conjunctival surface to prevent corneal
abrasion. Place a 6-0 silk vertical mattress alignment suture
through the tarsus at the lid margin and another through the
lash line. Tie these with enough tension to slightly evert the
wound at the lid margin. Leave the marginal suture ends long.
If necessary, place several additional Vicryl sutures to close the
eyelid retractors below the tarsus.
FIG. 31.7. Drape the skin–muscle ap over the lid and
pull it laterally with moderate tension. Mark the excess that
overlaps the lateral incision line, and cut along this mark with
scissors. It may be necessary to trim 2 to 3 mm of skin from
along the lid margin.
FIG. 31.8. Place one or two deep 6-0 chromic sutures at
the lateral wound to anchor the orbicularis. Close the skin
along the lid margin and at the lateral wound with interrupted
sutures. Tie the long, marginal silk suture ends into one or two
skin stitches to keep them away from the cornea.
FIG. 31.1. Mark an incision line 2 to 3 mm below the
lid margin from just lateral to the inferior punctum to
the lateral canthus. Extend the line laterally and slightly
downward for 1 cm as for a blepharoplasty incision.
FIG. 31.2. Pull the lid laterally to prevent buckling, and
cut the skin along the marked incision line with a rounded
scalpel blade.
FIG. 31.3. With scissors cut through the orbicularis muscle
and dissect a skin–muscle ap by dividing the ne fascial
attachments between the orbicularis and underlying
orbital septum.
FIG. 31.4. At the junction of the central and lateral thirds
of the eyelid, make an angled cut through the tarsus and
the conjunctiva from the lid margin to the fornix in an
inferomedial direction.
FIG. 31.5. With toothed forceps, grasp the free tarsal
edges and overlap them with moderate tension. Mark the
V-shaped area of excess lid, with the point of the V in the
conjunctival fornix.
INDICATIONS: Ectropion rom dif use horizontal eyelid laxity; oppy eyelid syndrome.
Full-thickness Marginal Wedge Resection
POSTOPERATIVE CARE: Apply iced compresses inter-
mittently or 24 hours. Place antibiotic ointment on the
suture line and in the ornix our times daily or 7 days.
Remove the silk marginal suture a ter 7 days.
POTENTIAL COMPLICATIONS:
Corneal abrasion—T is may result rom placing the lid
excision centrally and the tarsal sutures through the
conjunctiva. It may also result rom not care ully tying
the marginal sutures away rom the lid margin.
Eyelid margin notch—T is results rom poor tarsal clo-
sure and ailure to evert the margin with mattress
sutures. It may also ollow as a result o wound dehis-
cence. T e condition is repaired with wound revision
a ter several months.

113
CHAPTER 31 ▼ Full-thickness Marginal Wedge Resection
FIG. 31.1
FIG. 31.2
FIG. 31.3
FIG. 31.4
FIG. 31.5
FIG. 31.6
FIG. 31.7
FIG. 31.8

114
32
FIG. 32.5. Close the horizontal incision with several
6-0 plain or chromic gut sutures to shorten the posterior
lamella. Bury the knots to prevent corneal abrasion.
FIG. 32.6. Pass a 6-0 silk vertical mattress suture across
the tarsal defect at the eyelid margin for alignment.
Reapproximate the cut tarsal sur aces with several 6-0 Vicryl
sutures, keeping them beneath the conjunctiva.
FIG. 32.7. Place a second marginal 6-0 silk suture through
the lash line. ie the marginal sutures with enough tension to
evert the wound edges slightly, and leave the suture ends long.
ie together the remaining tarsal sutures.
FIG. 32.8. Close the orbicularis muscle with interrupted
6-0 chromic gut sutures and the skin with 6-0 fast-
absorbing plain gut. ie the long ends o the marginal sutures
into these skin stitches to keep them of the cornea.
FIG. 32.1. Hold the lid margin with two forceps, and with
scissors make a full-thickness vertical cut through the lid
4 mm lateral to the inferior punctum. Cauterize the marginal
artery.
FIG. 32.2. With forceps, grasp the two free tarsal edges and
overlap them with moderate tension. On the lateral side o
the wound, mark the amount o excess lid to be resected.
FIG. 32.3. Cut along the mark with scissors to excise a
V-shaped segment of full-thickness eyelid.
FIG. 32.4. Evert the medial portion of the eyelid with
forceps. Place a no. 00 or 0 Bowman probe into the canaliculus
to mark its location. Cut a horizontal V-shaped segment o
conjunctiva and capsulopalpebral ascia 4 mm below the
canaliculus. T e excised wedge should measure about 5 mm
vertically by 8 mm horizontally and should have its broad base
laterally, at the previously cut vertical eyelid de ect.
INDICATIONS: Dif use horizontal eyelid laxity with moderate punctal eversion.
Modi ed Lazy-T Procedure
POSTOPERATIVE CARE: Apply antibiotic ointment to the
sutures and conjunctival ornix our times daily or 10 days.
POTENTIAL COMPLICATIONS:
Canalicular injury—T is is caused by placement o the
in rapunctal incision or sutures too close to the cana-
liculus. Remain 4 mm below the position o the probe.
Eyelid margin notch—T is results rom poor marginal
wound closure and ailure to evert the wound edges. It
may be repaired secondarily by resecting a small wedge
with primary layered closure.

115
CHAP ER 32 ▼ Modi ied Lazy- Procedure
FIG. 32.3
FIG. 32.1
FIG. 32.2
FIG. 32.4
FIG. 32.6
FIG. 32.7
FIG. 32.5
FIG. 32.8

116
33
FIG. 33.4. Place a double-armed 5-0 prolene suture
vertically through the medial canthal ligament near its
insertion. Take care not to enter the lacrimal sac. Pass each
arm of the suture longitudinally through the inferior crus to
emerge near its origin on the tarsus. Note the position of the
Bowman probe to avoid injuring the canaliculus.
FIG. 33.5. Tie the suture to tuck the ligament and pull the
punctum medially to a normal position 5 to 6 mm from the
canthal angle.
FIG. 33.6. Close the skin with a running stitch of 6-0
fast-absorbing plain gut. Perform other lid shortening
procedures as needed.
FIG. 33.1. Place a no. 00 or 0 Bowman probe into the
inferior canaliculus to indicate its location. Mark a skin
incision line 2 mm below the cilia, beginning 3 mm lateral to
the punctum. Carry the line around the medial canthal angle
to 2 mm above the canthal ligament.
FIG. 33.2. Cut the skin along the marked line with a scalpel
blade.
FIG. 33.3. With forceps, tent up the orbicularis and carefully
cut through it. With blunt dissection, expose the inferior crus
of the canthal ligament and trace it to its insertion onto the
frontal process of the maxillary bone.
INDICATIONS: Laxity of the medial canthal ligament with medial ectropion or punctal eversion. T is may be combined
with any other procedure for ectropion repair.
Medial Canthal Ligament Plication
POSTOPERATIVE CARE: Apply antibiotic ointment to
the suture line four times daily for 5 days.
POTENTIAL COMPLICATIONS:
Canalicular occlusion—Placement of the plication suture
around or through the canaliculus will occlude its lumen
and result in possible epiphora.

117
CHAPTER 33 ▼ Medial Canthal Ligament Plication
FIG. 32.3
FIG. 33.2
FIG. 33.1
FIG. 33.6
FIG. 33.5
FIG. 33.4

118
FIG. 34.1. Mark an incision line 2 mm below the lid margin
from just lateral to the inferior punctum to just above the
lateral canthal angle. Extend the line laterally and slightly
in eriorly in a skin crease or a distance o 1 cm, as or lower
eyelid blepharoplasty. Hold the eyelid taut to prevent buckling
and cut the skin with a rounded scalpel blade along the
marked line.
FIG. 34.2. With forceps, tent up the skin edges at the lateral
end of the wound and cut through the orbicularis muscle.
Spread the divided muscle to enter the postorbicular areolar
plane. Open the muscle along the lid margin and dissect a
skin–muscle ap rom the underlying orbital septum.
FIG. 34.3. If necessary, perform a lid shortening procedure
at this point. Dissect laterally in the postorbicular ascial
plane toward the ear. Continue the dissection 4 to 5 cm rom
the lateral orbital rim to expose the deep temporalis ascia
covering the temporalis muscle.
FIG. 34.4. Make two parallel cuts in the fascia 5 to 6 mm
apart and 1 mm above the lateral canthus. ake care to
avoid injuring the underlying temporalis muscle. Extend these
cuts toward the upper margin o the ear or a distance o 4 cm.
Continue the cuts anteriorly through the periosteum covering
the lateral orbital rim. Cut the distal end o the ascial strip
(toward the ear) with long, curved scissors.
FIG. 34.5. Divide any ne attachments between the fascia
and underlying temporalis muscle. Raise the periosteal
34
INDICATIONS: Paralytic ectropion or recurrent lower eyelid laxity where vertical support is needed.
portion o the strip over the anterior edge o the orbital rim
with a Freer elevator. Rotate the ascial strip medially into the
lower eyelid de ect.
FIG. 34.6. Make an incision 5 to 6 mm long, inferior and
medial to the medial canthal ligament. Expose the ligament
and surrounding periosteum with blunt dissection. Pass a
Wright needle rom the medial canthal incision beneath the
orbicularis muscle and laterally to the lower lid incision. T read
the ascial strip into the needle eyelet and pull it through to the
medial canthal ligament.
FIG. 34.7. Put enough tension on the fascia to pull the lid
margin against the globe and to position it 2 mm above the
inferior corneal limbus. Mark the point where the ascial strip
contacts the insertion o the medial canthal ligament. rim of
the excess. Pass a double-armed 5-0 prolene suture through the
insertion o the medial canthal ligament and then through the
ascial strip.
FIG. 34.8. Fix the fascia to the tarsus just below the lid
margin with 4 to 5 interrupted 6-0 prolene sutures. Close
the medial canthal incision with interrupted 6-0 ast-absorbing
plain gut. Drape the skin–muscle ap over the lid and close
the orbicularis muscle laterally with several buried 6-0 chromic
or Vicryl sutures. Close the skin with a running suture o 6-0
ast-absorbing plain gut.
Temporal Fascia Lower Eyelid Suspension
POSTOPERATIVE CARE: Place a f rm dressing or 24
hours. Apply cold compresses intermittently or 24 hours
a ter the dressing is removed. Place antibiotic ointment on
the suture lines our times daily or 7 days.
POTENTIAL COMPLICATIONS:
Lateral canthal angle dystopia—T is is caused by poor
positioning o the ascial strip on the lateral orbital wall.
T e point o origin o the strip should be 1 mm above
the lateral canthal angle.
Lateral canthal angle ectropion—T is is seen when the
ascial strip origin is at the external sur ace o the lateral
orbital rim. T e periosteal extension o the strip should
be dissected around the rim so that it originates rom
the inner sur ace.
Ectropion—T is results rom ailure to suture the ascial
strip to the tarsus or placement o the strip too low in
the eyelid. T e strip should be placed in contact with the
ull width o the tarsus.

119
CHAP ER 34 ▼ emporal Fascia Lower Eyelid Suspension
FIG. 34.6
FIG. 34.7
FIG. 34.8
FIG. 34.5
FIG. 34.3
FIG. 34.2
FIG. 34.1
FIG. 34.4

120
35
FIG. 35.1. Mark the line of incision 3 mm below the eyelid
margin or along the upper edge of the contracted area
of skin if nonmarginal. Extend the line at least 6 to 8 mm on
either side of the contracted area. Place a traction suture of
4-0 silk through the marginal tarsus.
FIG. 35.2. Cut along the marked incision line with a
scalpel blade. Sharply dissect the skin from the underlying
orbicularis muscle for a distance of 5 to 6 mm beyond all
areas of contraction. Divide any prominent scar bands. When
free, the eyelid margin should overlap the corneal limbus
without tension by 1 to 2 mm. Obtain meticulous hemostasis
with pressure or epinephrine-soaked gauze. Avoid excessive
cautery.
FIG. 35.3. Mark an incision line in the supratarsal
eyelid crease of the ipsilateral or contralateral upper
eyelid. Outline an elliptical segment, as for upper eyelid
blepharoplasty. T e width of the graft should be 1.5 times the
width of the recipient bed defect.
FIG. 35.4. Cut the donor skin along the marked line with a
scalpel blade. Undermine the graft with scissors and dissect
it from the orbicularis muscle. It may be necessary to excise
part of the muscle to allow closure of the wound. Close the
donor site with a running suture of 6-0 fast-absorbing
plain gut.
FIG. 35.5. If a larger graft is needed, an alternative donor
site is retroauricular skin. Center the graft at the posterior
base of the ear so that half extends onto the retroauricular skin
and half onto the non–hair-bearing supramastoid skin. Mark
the graft the appropriate shape and 1.5 times the width of the
recipient defect. Cut the skin with a scalpel blade and dissect
the skin from subcutaneous tissue with scissors. Close the
donor site with a running stitch of 4-0 Vicryl.
FIG. 35.6. Remove all subcutaneous tissue from the skin
graft with sharp dissection. If needed, trim the graft to t the
defect, keeping it 1.5 times the required width.
FIG. 35.7. Suture the graft into the recipient bed using
interrupted 7-0 Vicryl stitches. Fibrin tissue glue can be used
to help x the graft in position. If the graft is larger than 2 cm in
diameter, cut one or more stab incisions in its central portion
for drainage. Place a 4-0 silk Frost suture through the eyelid
margin and tape it to the brow to keep the eyelid closed and
the graft at.
FIG. 35.8. Pass a 5-0 nylon vertical mattress suture
through the skin beyond the graft edges centrally, and put
additional mattress sutures on either side. Place a elfa pad
soaked in antibiotic solution over the graft, and position a
rolled sterile sponge or dental roll over the pad. ie the mat-
tress sutures snugly to keep the graft immobile.
INDICATIONS: Moderate to severe cicatricial ectropion due to anterior lamellar shortening.
Anterior Lamellar Eyelid Lengthening
with Skin Graft
POSTOPERATIVE CARE: Apply antibiotic ointment to
the suture line, and place a f rm dressing over the eyelids.
Change the dressing a ter 4 days. Remove the dressing and
Frost sutures a ter 10 days.
POTENTIAL COMPLICATIONS:
Persistent or recurrent ectropion—T is usually results
rom ailure to completely undermine the skin beyond
the area o cicatricial shortening or rom not allowing or
gra t shrinkage. T e gra t should be 1.5 times the width
o the shortest vertical dimension o the recipient de ect.
Lagophthalmos of the donor upper eyelid—T is may
be seen i too large a gra t is harvested rom an upper
eyelid without su cient redundant skin. Care ully
measure the excess skin available prior to cutting the
gra t.
Graft failure—T is is unusual but can occur i the donor
site is poorly vascularized, i hematoma results rom
inadequate hemostasis, or i the gra t is not properly
stented or 10 days so that it lies in intimate contact with
its vascular bed.

121
CHAP ER 35 ▼ Anterior Lamellar Eyelid Lengthening with Skin Graft
FIG. 35.1
FIG. 35.2
FIG. 35.3
FIG. 35.4
FIG. 35.5
FIG. 35.6
FIG. 35.7
FIG. 35.8

(Trang không có chữ)

123
SECTIONI
E
ntropion is a turning inward o the eyelid margin. Like
ectropion, the causes are numerous, but unlike the latter,
the results may be ar more devastating to the eye. Whatever
the specif c etiology, in the presence o entropion, both the
mucocutaneous border o the eyelid and the lashes are
directed toward the globe, resulting in conjunctival irritation
and corneal abrasion. In some cases, as with cicatricial ocu-
lar pemphigoid, distortion o eyelid tissues may include a true
trichiasis in addition to entropion. However, in most cases o
entropion, the lashes are in a normal position relative to the
lid margin, and the resulting corneal touch is secondary to the
lid malposition.
T e clinical spectrum o entropion ranges rom mild,
intermittent backward tilting o the marginal tarsus
associated with only occasional corneal touch to severe
180-degree inversion o the eyelid, with the lashes and skin
in ull contact with the cornea. T e resulting ocular sur ace
irritation is associated with conjunctival injection, re ex
lacrimation and epiphora, and ocular discom ort rom cor-
neal epithelial disruption. A secondary blepharospasm is
requently present, which exacerbates the condition.
Entropion may be classif ed into congenital, involu-
tional, cicatricial, and mechanical types, each with its
own di erent pathophysiology. T e anatomic basis or the
de ormity must be understood i e ective correction is to
be achieved. Although relie o symptoms is accomplished
with a number o simple procedures, some o which are
use ul in selected situations, permanent correction is only
attained by care ul restoration o normal anatomical and
physiologic relationships.
Congenital entropion in the upper eyelid is unusual but
may be associated with a de ormity o the tarsal plate, as in
the tarsal kink syndrome. It also occurs with incomplete
development o the tarsus, which includes absence o the lid
crease and overriding o the orbicularis muscle. Correction
usually requires a marginal rotation procedure and re or-
mation o the eyelid crease. rue congenital entropion in
the lower eyelid is exceptionally rare, and in most cases,
a secondary entropion results rom epiblepharon. In this
case, the tarsus is in a normal position relative to the pri-
mary position o gaze. Absence o the lower eyelid crease
results in upward override o skin and orbicularis muscle
and mild entropion during downgaze. T e condition usu-
ally resolves spontaneously during the second or third year
o li e. Repair may be necessary when there is signif cant
corneal irritation and is directed at ref xation o the prese-
ptal orbicularis muscle by ormation o the eyelid crease.
T is may be achieved with ull-thickness eyelid sutures
because the temporary e ect o this type o procedure
generally lasts until the condition corrects itsel . When this
disorder persists into later childhood or adulthood, a more
permanent procedure is indicated with resection o a small
segment o skin and muscle with direct crease re ormation.
An acquired orm o epiblepharon may be seen in patients
ollowing eyelid surgery in which a subciliary skin–muscle
ap has been elevated to the eyelid margin and normal
ascial attachments between anterior and posterior lamel-
lae have been disrupted. It may also occur spontaneously,
associated with involutional changes. Repair consists o
re ormation o the lower eyelid crease, generally through a
direct skin incision approach.
T e most common kind o acquired entropion is o the
involutional type. T is results rom several anatomic alter-
ations in the aging eyelid and orbit. T e clinical f ndings
and symptoms depend on the balance o specif c causative
elements. Laxity o the eyelid is probably the most impor-
tant actor in tarsal malposition. Most requently, lax-
ity results rom stretching o the lateral canthal ligament,
which is the weakest segment o lower eyelid support, but
it may also involve generalized laxity o the entire tarsal
plate and medial canthal ligament. T e laxity commonly
also involves skin and muscle o the anterior lamella. When
other involutional changes are absent, the only symptoms
o eyelid laxity may be epiphora caused by loss o orbi-
cularis muscle tone and corneal exposure, or ectropion
attributable to ocular sur ace–eyelid length disparity.
When eyelid laxity is associated with redundancy o the
lower lid retractors, tarsal instability and mild entropion
may result. Loss o retractor f xation in the presence o nor-
mal eyelid tone, however, does not typically produce entro-
pion. Involutional orbital at atrophy and enophthalmos
urther contribute to eyelid accidity and inward rotation
o the tarsal plate margin. Loss o f ne ascial attachments
between the orbicularis muscle and underlying orbital
septum allows upward overriding o preseptal f bers onto
the tarsus and pretarsal orbicularis. When associated
with signif cant horizontal eyelid redundancy and laxity
o the retractors, this shi t in the rotational vector around
the canthal ligaments produces signif cant entropion. It
is more marked in patients with a relatively narrow tar-
sal plate. With persistent secondary blepharospasm rom
corneal irritation and subsequent preseptal muscle hyper-
trophy, this process may eventually dominate the picture,
resulting in what has been re erred to as “chronic spastic
entropion.” However, this is a secondary condition, not a
primary one. An acute orm o “spastic entropion” results
Entropion

rom secondary blepharospasm ollowing eye surgery
or ocular sur ace irritation in the presence o otherwise
asymptomatic, predisposing, involutional eyelid changes.
T e surgical correction o involutional entropion is
directed at repair o the primary anatomic de ects. I eyelid
laxity is the only signif cant f nding, repair may be achieved
with simple horizontal lid shortening. When horizontal lid
laxity is minimal but retractor redundancy or rank disin-
sertion is the major actor, tightening or reattachment o
the retractors alone will correct the entropion. In most
cases, however, laxity will also require f xation o the pre-
septal orbicularis muscle to the capsulopalpebral ascia in
order to prevent override. When both horizontal eyelid
and vertical retractor laxity are signif cant, as is commonly
the case, horizontal lid shortening by lateral canthal liga-
ment tucking, ull-thickness pentagonal wedge resection,
or lateral tarsal strip f xation will be necessary in addition
to retractor repair.
A less satis actory procedure is the placement o ull-
thickness Quickert-Rathbun type sutures to create f xation
o the preseptal orbicularis and tightening o the retractors.
T e advantage o the operation is that it can be per ormed
at the bedside o patients who are unable to undergo more
def nitive surgery. However, its results tend to be tempo-
rary because it does not correct the major de ect o eyelid
laxity, nor does it permanently reattach the retractors to
the tarsal plate.
Cicatricial entropion occurs when de ormation orces
are applied to the tarsus in such a way that it is bent inward
toward the globe. Such orces are seen in cicatricial dis-
eases o the conjunctiva, such as ocular pemphigoid or
Stevens-Johnson syndrome. More permanent distortion
o the tarsal shape may be associated with chemical burns,
traumatic injuries, or in ectious processes such as tra-
choma. A congenital kinking o the tarsal plate produces
a similar picture. T e symptoms associated with cicatricial
entropion are similar to those o involutional entropion,
with the requent addition o severe dry eyes caused by a
loss o accessory lacrimal glands, mechanical corneal abra-
sion rom conjunctival scarring, and chronic exposure
when lagophthalmos is signif cant.
Correction o cicatricial entropion is aimed at restora-
tion o the def cient posterior lamella, either the conjunc-
tiva alone or the conjunctiva plus the tarsus. Four basic
approaches have been used in a variety o described proce-
dures, depending upon the anatomic de ect. Simple short-
ening o the anterior skin and muscle lamella may be use ul
in very mild cases that are not associated with appreciable
tarsal de ormity. T is can be achieved by resection o skin
and muscle with epitarsal f xation, or less permanently
with ull-thickness Quickert-Rathbun type o sutures.
When tarsus is buckled inward or conjunctival shorten-
ing is the principle cause, lengthening o the posterior
lamella with mucous membrane or tarsal gra ting is neces-
sary. Eyelid margin entropion, when mild, may be repaired
by a marginal lid-splitting procedure, with or without an
interposing gra t. When the entropion is more severe, one
o the marginal rotation operations is more appropriate.
Mechanical entropion is seen with mass lesions o the
eyelid that secondarily invert the lid margin. T ese may be
in ammatory or neoplastic. Management must be directed
at the source o the pathologic process, with any residual
eyelid malposition repaired as necessary.
Evaluation o the patient with entropion attempts to
determine the status o the various components o eyelid
anatomy that may be associated with marginal instabil-
ity. T is must include components o the horizontal eyelid
support sling, in which group are the medial and lateral
canthal ligaments, as well as the tarsal plate and tone o
the orbicularis muscle. I the central eyelid margin can be
pulled away rom the globe more than 7 to 8 mm without
undue tension, horizontal laxity is present. In such cases,
the lid will not snap back into apposition with the globe as
it does when tone is normal. Rather, the lax eyelid slowly
dri ts back into position. On pulling the lid margin later-
ally, an increase o more than 3 to 4 mm in the distance
between the medial canthal angle and punctum indicates
signif cant stretching o the medial canthal ligament. On
orced lid closure, the lid becomes entropic, and with loss
o retractor f xation, the in erior border o the unstable tar-
sus will rotate outward where it is easily palpable through
the skin. Gentle palpation just beneath the tarsus during
vertical gaze shi ts may demonstrate the disinserted edge
o the lower lid retractors. In such cases, the conjunctival
ornix, which is usually white because o the underlying
retractor sheet, may appear pink because o the presence
o orbicularis muscle immediately behind the conjunctiva.
When the retractors are merely redundant without true
disinsertion, these f ndings are absent. T e presence o a
deep supratarsal sulcus and exophthalmometry o <12 to
14 mm suggests enophthalmos is a contributing actor.
SUGGESTED FURTHER READING
Entropion
Benger RS, Musch DC. A comparative study o eyelid parameters in invo-
lutional entropion. Ophthal Plast Reconstr Surg. 1989;5:281–287.
Bernardino CR. Alternative etiology and surgical correction o acquired
lower-eyelid entropion. Ann Plast Surg. 2007;59:229.
Bernardino R, Chang EL, Rubin PA. Entropion. Ophthalmology. 2011;
118:226–227.
Dryden RM, Leibsohn J, Wobig J. Senile entropion, pathogenesis and
treatment. Arch Ophthalmol. 1978;96:1883–1885.
Kakizaki H, Zako M, Kinoshita S, Iwaki M. Posterior layer advancement
o the lower eyelid retractor in involutional entropion repair. Ophthal
Plast Reconstr Surg. 2007;23:292–295.
Kocaoglu FA, Katircioglu YA, ok OY, et al. T e histopathology o involu-
tional ectropion and entropion. Can J Ophthalmol. 2009;44:677–679.
Olver JM, Barnes JA. E ective small-incision surgery or involutional
lower eyelid entropion. Ophthalmology. 2000;107:1982–1988.
Shore JW. Changes in lower eyelid resting position, movement, and treat-
ment, and tone with age. Am J Ophthalmol. 1985;99:415–423.
Marginal Rotation
Bleyen I, Dolman PJ. T e Wies procedure or management o trichiasis or
cicatricial entropion o either upper or lower eyelids. Br J Ophthalmol.
2009;93:1612–1615.
124 SECTION I ▲ Entropion

Swamy BN, Benger R, aylor S. Cicatricial entropion repair with hard
palate mucous membrane gra t: surgical technique and outcomes.
Clin Exp Ophthalmol. 2008;36:348–352.
T ommy CP. Scleral homogra t inlay or correction o cicatricial entropion
and trichiasis. Br J Ophthalmol. 1981;65:198–201.
Quickert-Rathbun Sutures
Miyamoto , Eguchi H, Katome , et al. E cacy o the Quickert proce-
dure or involutional entropion. T e f rst case series in Asia. J Med
Invest. 2012;59:136–142.
Pereira MG, Rodrigues MA, Rodrigues SA. Eyelid entropion. Semin
Ophthalmol. 2010;25:52–58.
Quist LH. arsal strip combined with modif ed Quickert-Rathbun sutures
or involutional entropion. Can J Ophthalmol. 2002;37:238–244.
Retractor Reinsertion
Caldato R, Lauande-Pimentel R, Sabrosa NA, et al. Role o reinsertion o
the lower eyelid retractor on involutional entropion. Br J Ophthalmol.
2000;84:606–608.
Erb MH, Uzcategui N, Dresner SC. E cacy and complications o the
transconjunctival entropion repair or lower eyelid involutional entro-
pion. Ophthalmology. 2006;113:2351–2356.
T en SY, Salam A, Kakizaki H, Malhotra R. A lateral approach to
lower eyelid entropion repair. Ophthalmic Surg Lasers Imaging.
2011;42:519–522.
Dutton JJ, awf k HA, DeBacker CM, Lipham WJ. Anterior tarsal
V-wedge resection or cicatricial entropion. Ophthal Plast Reconstr
Surg. 2000;16:126–130.
Hoh HB, Harrad RA. Factors a ecting the success rate o the Quick-
ert and Wies procedures or lower lid entropion. Orbit. 1998;17:
169–172.
Yagci A, Palamar M. Long-term results o tarsal marginal rotation and
extended lamellae advancement or end stage trachoma. Ophthal
Plast Reconstr Surg. 2012;28:11–13.
Mucous Membrane and Hard Palate Graft
Bartley GB, Kay PP. Posterior lamellar eyelid reconstruction with a hard
palate mucosal gra t. Am J Ophthalmol. 1989;107:609–612.
Dryden RM, Soll DB. T e use o scleral transplantation in cicatricial
entropion and eyelid retraction. Trans Sect Ophthalmol Am Acad
Ophthalmol Otolaryngol. 1977;83:669–678.
Goldberg RA, Joshi AR, McCann JD, Shorr N. Management o severe
cicatricial entropion using shared mucosal gra ts. Arch Ophthalmol.
1999;117:1255–1259.
Koreen IV, aich A, Elner VM. Anterior lamellar recession with buccal
mucous membrane gra ting or cicatricial entropion. Ophthal Plast
Reconstr Surg. 2009;25:180–184.
Matsuo K, Hirose . T e use o conchal cartilage gra t in involutional
entropion. Plast Reconstr Surg. 1990;86:968–970.
125
SECTION I ▼ Entropion

126
36
FIG. 36.3. Pull the skin downward slightly and move the
needle point upward beneath the skin to a position 3 mm
below the eyelid margin. Push the needle through the skin.
FIG. 36.4. Pass the second arm of the mattress suture in
a similar fashion 3 to 4 mm from the rst arm. Place two
additional mattress sutures 8 mm medial and lateral to the
rst. Tie all three sutures rmly without bolsters, and adjust the
tension to produce a slight ectropion. Place ve to six throws in
the knot to prevent loosening.
FIG. 36.1. Grasp the lower eyelid with a toothed forceps
and gently pull it away from the globe. Place one arm of a
double-armed 4-0 chromic suture on a large, curved needle
into the inferior conjunctival fornix just lateral to the
central eyelid.
FIG. 36.2. Push the needle straight through the
conjunctiva, capsulopalpebral fascia, and orbital
septum until the needle point is just visible beneath
the skin.
INDICATIONS: Mild to moderate involutional entropion; acute spastic entropion ollowing ocular surgery; mild
cicatricial entropion when more def nitive procedures cannot be per ormed.
Full-thickness Eyelid Sutures
(Quickert-Rathbun)
POSTOPERATIVE CARE: Place antibiotic ointment in
the conjunctival ornix and on the skin sutures our times
daily until the sutures all out.
POTENTIAL COMPLICATIONS:
Overcorrection—T is is caused by excessive tightening o
the sutures, especially when there is signif cant eyelid
laxity. T e situation is usually temporary, and correction
may be hastened with massage to so ten the scar bands.
Recurrence—T is is common and results rom the inabil-
ity o the operation to reattach the retractors to the tar-
sus. T e procedure f xes the retractors to the orbicularis
muscle and serves mainly to prevent preseptal muscle
override.

127
CHAPTER 36 ▼ Full-thickness Eyelid Sutures (Quickert-Rathbun)
FIG. 36.1
FIG. 36.2
FIG. 36.3
FIG. 36.4

128
37
full-thickness of the eyelid centrally from just below the inferior
tarsal border to exit at the premarked crease line.
FIG. 37.3. Pass the second arm of the suture 3 mm from the
rst, and tie the stitch rmly without a bolster.
FIG. 37.4. Place two additional mattress sutures along the
marked line in the medial two-thirds of the eyelid.
FIG. 37.1. Mark the intended position of the lower eyelid
crease, beginning below the punctum, 3 mm beneath the
eyelid margin. Extend the mark laterally to the junction of the
middle and lateral thirds of the lid and slightly downward to
5 mm from the margin.
FIG. 37.2. Grasp the central eyelid margin with toothed
forceps and pull the lid gently away from the globe. Pass
one arm of a double-armed 4-0 chromic suture through the
INDICATIONS: Congenital or acquired epiblepharon with corneal irritation.
Modi ed Full-thickness Eyelid Sutures
for Epiblepharon Repair
POSTOPERATIVE CARE: Place antibiotic ointment in
the conjunctival fornix and on the skin sutures four times
daily until the sutures fall out.

129
CHAPTER 37 ▼ Modified Full-thickness Eyelid Sutures for Epiblepharon Repair
FIG. 37.1
FIG. 37.2
FIG. 37.3
FIG. 37.4

130
38
FIG. 38.1. Mark the position of the intended lower eyelid
crease, beginning 3 mm below the inferior punctum. Extend
the line laterally and slightly downward to the junction of the
middle and lateral thirds of the eyelid. Here the line should be
5 mm below the lid margin.
FIG. 38.2. Hold the skin taut to prevent buckling and cut
the skin with a scalpel blade along the marked line.
FIG. 38.3. Tent up the skin edges with toothed forceps and
cut through the pretarsal orbicularis muscle with scissors.
Dissect downward in the postorbicular fascial plane with
scissors for a distance of 5 mm to reveal the orbital septum
and eyelid retractors.
FIG. 38.4. Using forceps, gently pull the marginal
skin– muscle ap downward to slightly evert the lash line
into a normal position. Pull the inferior skin–muscle ap
upward, over the marginal ap. Mark the excess skin and
muscle strip on the inferior ap. T is should usually not exceed
2 to 4 mm.
FIG. 38.5. With scissors, cut the excess skin and muscle from
the lower ap.
FIG. 38.6. Close the skin edges with interrupted
6-0 fast-absorbing plain gut sutures. Each suture should pass
through the eyelid retractors at the inferior border of the tarsus
to x the muscle.
INDICATIONS: Congenital and acquired epiblepharon with corneal irritation, especially in older children and adults.
Lower Eyelid Crease Reformation for
Epiblepharon Correction
POSTOPERATIVE CARE: Apply antibiotic ointment to
the suture line four times daily until the sutures dissolve.

131
CHAP ER 38 ▼ Lower Eyelid Crease Reformation for Epiblepharon Correction
FIG. 38.1
FIG. 38.2
FIG. 38.3
FIG. 38.4
FIG. 38.5
FIG. 38.6

132
39
INDICATIONS: Involutional entropion with vertical redundancy or disinsertion o the lower eyelid retractors.
FIG. 39.1. Mark the proposed incision line 2 to 3 mm below
the lower eyelid margin from the inferior punctum to the
lateral canthal angle and then slightly downward in a laugh
line for a distance of 10 mm.
FIG. 39.2. Hold the skin taut to prevent buckling and with a
scalpel blade cut it along the marked line.
FIG. 39.3. Tent up the skin edges with forceps and cut
through the orbicularis muscle temporally with scissors.
Open the muscle along the entire length of the skin incision.
FIG. 39.4. With scissors dissect downward in the postor-
bicular fascial plane to the inferior orbital rim to expose
the orbital septum. Open the septum across the length of
the eyelid. If the retractors are disinserted, the edge of the
capsulopalpebral fascia may be seen some distance below
the inferior tarsal border, thus revealing Müller’s muscle and
conjunctiva.
FIG. 39.5. Place a 6-0 prolene suture through the edge of the
capsulopalpebral fascia if disinserted or 4 to 6 mm below
the tarsus if it is inserted but redundant. Pass the suture into
the inferior border of the tarsal plate. Tie the suture. Adjust the
position of the suture on the capsulopalpebral fascia until the
eyelid margin retracts 3 to 4 mm on downward gaze. Suture the
remaining edge of the fascia to the tarsus with four additional
6-0 prolene sutures. Do not shorten the orbital septum.
FIG. 39.6. Drape the skin and muscle ap upward and with
gentle tension pull the ap laterally. Mark the excess skin
along the lid margin and at the lateral wound edge. Cut the
excess skin and muscle along the mark. Rarely is it necessary to
remove more than 2 to 4 mm of vertical skin.
FIG. 39.7. Internally reform the lower eyelid crease by
placing several 7-0 chromic sutures through the orbicularis
muscle 5 to 6 mm below the edge of the inferior wound and
through the capsulopalpebral fascia just below the tarsal
plate.
FIG. 39.8. Close the skin edges with a running stitch of
6-0 fast absorbing plain gut below the eyelid margin and
with several interrupted stitches beyond the lateral canthus.
Lower Eyelid Retractor Reinsertion
POSTOPERATIVE CARE: Apply iced compresses to the
eyelid intermittently or 24 hours. Apply antibiotic oint-
ment to the suture line our times daily or 7 days.
POTENTIAL COMPLICATIONS:
Recurrence of entropion—T is results rom ailure to
adequately tighten the retractors when redundant. It is
also seen when horizontal eyelid laxity is present and
not simultaneously repaired.
Ectropion—T is is caused by placement o f xation sutures
too high on the anterior tarsal ace. I the ectropion is
minimal, it may be corrected with massage or a lateral
tarsal strip–tightening procedure.
Eyelid retraction—T is may result rom excessive tucking
o the capsulopalpebral ascia.

133
CHAPTER 39 ▼ Lower Eyelid Retractor Reinsertion
FIG. 39.1
FIG. 39.2
FIG. 39.3
FIG. 39.4
FIG. 39.6
FIG. 39.7
FIG. 39.8
FIG. 39.5

134
40
and slightly medially so that the resulting wedge resec-
tion is 2 to 3 mm wider at the tarsal base than at the eyelid
margin. Complete the pentagonal resection by extending this
cut to the inferior fornix. Repair the marginal eyelid defect
as described for Direct Layered Closure of Marginal Defects,
Fig. 56.2 through 56.5 (pp. 214 to 215).
FIG. 40.4. Drape the skin and muscle ap upward and
with gentle tension pull it laterally over the wound edges.
Mark the excess ap and excise it with scissors. Rarely is it
necessary to remove more than 2 to 4 mm vertically. Place
four to ve interrupted 7-0 chromic sutures through the
preseptal orbicularis muscle 5 to 6 mm below the skin edge
and through the capsulopalpebral fascia. Close the skin edges
with a running stitch of 6-0 fast-absorbing plain gut along the
lid margin and with interrupted sutures laterally.
FIG. 40.1. Proceed as for Lower Eyelid Retractor
Reinsertion, Fig. 39.1 through 39.5 (pp. 168 to 169). Mark a
vertical line at the junction of the central and lateral thirds of
the lid to the lower tarsal border and then angled medially to
the inferior fornix.
FIG. 40.2. Grasp the eyelid margin with a toothed forceps.
Cut along the marked line with scissors, from the lid margin to
the base of the tarsus. T e cut should be angled slightly laterally
at its inferior-most point. Extend the cut inferiorly and medially
to the lower conjunctival fornix. Hold the cut edges of the eyelid
margin with forceps and overlap them under slight tension. Mark
the amount of excess lid from the medial ap.
FIG. 40.3. With scissors make an angled vertical cut
through the tarsus at the mark, directing the cut inferiorly
INDICATIONS: Involutional entropion from retractor disinsertion combined with horizontal eyelid laxity.
Retractor Reinsertion with Horizontal
Eyelid Shortening
POSTOPERATIVE CARE: Apply iced compresses to the
eyelid intermittently for 24 hours. Place antibiotic oint-
ment to the suture line four times daily for 7 days.
POTENTIAL COMPLICATIONS:
Corneal abrasion—T is results from placement of marginal
sutures too close to the posterior eyelid surface or failure
to tie the suture ends onto the skin surface. If noted intra-
operatively, remove and replace the marginal sutures.
Postoperatively, a soft contact lens may be applied until
sutures are removed. Occasionally, the posterior mar-
ginal sutures may have to be removed early.
Wound dehiscence—T is may be caused by resection of
too much eyelid with repair under excessive tension. It
is corrected by freshening the wound margins if neces-
sary and resuturing the defect.

135
CHAP ER 40 ▼ Retractor Reinsertion with Horizontal Eyelid Shortening
FIG. 40.1
FIG. 40.2
FIG. 40.3
FIG. 40.4

136
41
FIG. 41.1. Proceed as for Lower Eyelid Retractor Reinsertion,
Fig. 39.1 through 39.5 (pp. 168 to 169). With forceps pull the
eyelid medially to straighten the lateral canthal ligament, and
with scissors cut a lateral canthotomy to the lateral orbital rim.
Turn the scissors downward and cut through the inferior crus
to free all lateral attachments of the eyelid.
FIG. 41.2. Pull the lid laterally and mark the amount to
be shortened. Split the lid along the gray line to this mark
and remove the strip of anterior skin and muscle. Detach the
retractors from this portion of the lid by cutting along the
inferior tarsal border. Cut a strip of marginal epithelium from
the tarsus, and scrape the conjunctival epithelium from the
posterior surface with a scalpel blade. Trim any excess canthal
ligament and tarsus to leave only a 3- to 4-mm strip of bare
tarsus.
FIG. 41.3. Place two single-armed sutures of 4-0 Mersilene
or Vicryl through the tarsal strip and into the periosteum
of the inside surface of the lateral orbital rim. Use of a small,
stout, half-curved needle facilitates this maneuver. Tie the
sutures.
FIG. 41.4. Drape the skin and muscle ap over the wound
edges without vertical tension. Mark and trim the excess
with scissors. Place four to ve interrupted 7-0 chromic sutures
through the preseptal orbicularis muscle 5 to 6 mm below the
skin edge and through the capsulopalpebral fascia about 5 to
6 mm below the lid margin. Close the orbicularis muscle with
interrupted 6-0 chromic sutures and the skin edges below the
eyelid margin with a running suture of 6-0 fast-absorbing plain
gut. Reform a sharp, lateral canthal angle with an interrupted
stitch.
INDICATIONS: Involutional entropion with laxity o the lateral canthal ligament.
Retractor Reinsertion with Lateral Tarsal
Strip Fixation
POSTOPERATIVE CARE: Apply iced compresses to the
eyelid intermittently or 24 hours. Place antibiotic oint-
ment on the suture line our times daily or 7 days.
POTENTIAL COMPLICATIONS:
Elevation of lateral canthal angle—T is results rom
placement o the periosteal sutures too high on the lat-
eral orbital rim. T e sutures should be positioned at, or
only very slightly higher than, the original insertion o
the in erior crus.
Lateral canthal angle ectropion—T is is caused by place-
ment o the periosteal suture on the outer sur ace o
the lateral orbital rim. T e tarsal strip must be sutured
against the inner rim wall.
Recurrent eyelid laxity—T is may be seen as a late complica-
tion i the tarsal strip is not f rmly secured to the periosteum.
Rounded canthal angle—T is results rom ailure to
re orm the canthal angle with a suture through the
upper and lower eyelid margins. It may be corrected
secondarily with a simple lateral canthoplasty.

137
CHAPTER 41 ▼ Retractor Reinsertion with Lateral Tarsal Strip Fixation
FIG. 41.1
FIG. 41.2
FIG. 41.3
FIG. 41.4

138
42
INDICATIONS: Mild cicatricial entropion without signif cant tarsal de ormity.
FIG. 42.1. Mark the line of incision along the upper eyelid
4 to 5 mm from the margin centrally and 3 to 4 mm from
the margin laterally and medially.
FIG. 42.2. Pull the eyelid laterally to prevent buckling, and
with a scalpel blade cut the skin along the marked incision
line.
FIG. 42.3. Tent up the skin edges with forceps and cut
through the orbicularis muscle with scissors to enter the
postorbicular fascial plane. Extend the incision along the
entire eyelid skin wound.
FIG. 42.4. With scissors, dissect in the postorbicular fascial
plane from the superior border of the tarsus to 2 mm from
the eyelid margin. Take care to avoid injuring the eyelash
bulbs.
FIG. 42.5. Pass a 6-0 prolene or Vicryl suture through the
orbicularis muscle on the marginal wound edge. Pull the
skin–muscle ap superiorly about 4 mm until the eyelid
margin is slightly rotated outward and pass the suture through
the super cial tarsus.
FIG. 42.6. Place additional sutures along the wound edge
in similar fashion and tie them so the entire eyelid margin
is slightly overcorrected and ectropic.
FIG. 42.7. If necessary, excise a small strip of skin and
muscle from the superior edge of the wound.
FIG. 42.8. Close the skin edges with a running stitch of
6-0 fast-absorbing plain gut, and reform the new eyelid
crease by taking deep bites into the levator aponeurosis or
the epitarsus with every second or third pass of the suture.
Anterior Lamellar Shortening with
Epitarsal Muscle Fixation
POSTOPERATIVE CARE: Apply iced compresses to the
eyelid intermittently or 24 hours. Place antibiotic oint-
ment on the suture line our times daily or 7 days and on
the globe until the ectropion resolves.
POTENTIAL COMPLICATIONS:
Undercorrection of entropion—T is results rom insu -
f cient shortening o the anterior lamella or ailure to
suture the orbicularis muscle to the tarsus. It also results
rom using this procedure in the presence o signif cant
tarsal de ormity. Following closure, the eyelid should be
slightly ectropic.
Overcorrection—T is is caused by excessive shortening o
the skin and muscle lamella and usually resolves with
time. Correction may be hastened with massage a ter 10
days.
Irregular eyelid crease—T is may result rom placement
o the epitarsal f xation sutures at uneven distances rom
the lid margin. Have the patient look up during place-
ment to conf rm the appropriate position. Slight irregu-
larities may correct spontaneously a ter several weeks,
but more signif cant de ormities may require secondary
crease re ormation.

139
CHAPTER 42 ▼ Anterior Lamellar Shortening with Epitarsal Muscle Fixation
FIG. 42.1
FIG. 42.2
FIG. 42.3
FIG. 42.5
FIG. 42.6
FIG. 42.7
FIG. 42.4
FIG. 42.8

140
43
FIG. 43.1. Mark an incision line 5 to 6 mm from the eyelid
margin. Place the lid on lateral tension to prevent buckling and
cut through the skin with a scalpel blade.
FIG. 43.2. With scissors dissect in the postorbicular fascial
plane to 2 mm from the lid margin to expose the anterior
tarsal surface. ake care to avoid injuring the eyelash bulbs.
FIG. 43.3. Place a lid plate beneath the eyelid. Cut a horizontal
V-shaped groove 4 mm from the lid margin along the entire
width of the tarsus and through only 85% to 90% of the tarsal
thickness. T e groove should be at least 3 mm wide at the ante-
rior tarsal surface. Alternatively, this can be cut with a radiofre-
quency cutting instrument using a diamond-shaped cutting wire.
FIG. 43.4. Close the tarsal groove with interrupted
6-0 prolene sutures passed only through the superior lips
of the groove. T e eyelid margin should be turned slightly
outward when tying the sutures. If necessary, reattach the levator
aponeurosis to the tarsus with interrupted 6-0 prolene stitches.
FIG. 43.5. Pull the marginal skin and muscle ap superiorly
and with slight tension to rotate the lashes outward. Suture
the orbicularis muscle to the superior border of the tarsus with
interrupted 6-0 prolene or Vicryl stitches.
FIG. 43.6. Close the skin with a running suture of 6-0 fast-
absorbing plain gut. If necessary, remove a strip of any excess
skin and muscle prior to closure.
INDICATIONS: Mild to moderate cicatricial marginal entropion with tarsal de ormity.
Marginal Eyelid Rotation by Anterior
Horizontal Tarsal Groove Resection
POSTOPERATIVE CARE: Apply iced compresses to the
eyelid intermittently or 24 hours. Place antibiotic oint-
ment on the suture line our times daily or 7 days.
POTENTIAL COMPLICATIONS:
Undercorrection—T is may result rom insuf cient
resection o the tarsus. T e groove must be at least 3
mm wide at the anterior tarsal sur ace, and on closure,
the eyelid should be somewhat overcorrected.
Corneal injury—T is can result rom making the incision
through ull-thickness tarsus while cutting the groove or
rom placing sutures through ull-thickness tarsus and
conjunctiva. It can be avoided by using a lid plate while
cutting the groove and by passing the sutures through
partial-thickness tarsus only.

141
CHAP ER 43 ▼ Marginal Eyelid Rotation by Anterior Horizontal arsal Groove Resection
FIG. 43.1
FIG. 43.2
FIG. 43.3
FIG. 43.4
FIG. 43.5
FIG. 43.6

142
44
FIG. 44.1. Mark a horizontal incision line across the upper
or lower eyelid 4 mm from the lid margin.
FIG. 44.2. Place a lid plate behind the lid, and with a scalpel
blade cut through the full-thickness of the eyelid in the
central portion of the mark. Be sure the cut is at the same
distance from the lid margin on both the skin and conjunctival
surfaces.
FIG. 44.3. With scissors extend the cut laterally and medially
across the full width of the tarsal plate. Do not extend
beyond the tarsus to avoid injury to the palpebral arteries.
FIG. 44.4. Pass a double-armed 5-0 chromic mattress
suture through the skin edge on the marginal bridge ap
and through the posterior one-half thickness of the tarsal
plate in the upper wound edge.
FIG. 44.5. Place two or more additional mattress sutures
in similar fashion, medial and lateral to the central suture.
ie the sutures tight enough to slightly evert the eyelid margin.
FIG. 44.6. Close the skin edges with a running stitch of
6-0 fast-absorbing plain gut. T e eyelid margin should be
slightly overcorrected.
INDICATIONS: Moderate to severe upper or lower eyelid cicatricial entropion from the tarsal deformity.
Horizontal Blepharotomy with Marginal
Eyelid Rotation (Wies Procedure)
POSTOPERATIVE CARE: Apply iced compresses to the
eyelid intermittently for 24 hours. Place antibiotic oint-
ment on the suture line and on the globe four times daily
for 7 days.
POTENTIAL COMPLICATIONS:
Overcorrection—Seen in the immediate postoperative
period, this condition is usually temporary. If persistent,
it may be corrected with massage or Ziegler-type light
cautery to contract the conjunctival surface.
Hemorrhage—T is may result from injury to the palpebral
artery when extending the blepharotomy toward the
canthal angles. Injury to both palpebral arteries could
compromise vascular supply and, in rare instances, may
cause necrosis of the marginal bridge.
Corneal abrasion—T is can be caused by the chromic
sutures being passed onto the conjunctival surface. It
is important to place the suture subconjunctivally, with
the knot toward the skin surface.